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http://dx.doi.org/10.5624/isd.2016.46.1.17
Department of Dental Radiology, School of Dentistry, Ponta Grossa State University, Ponta Grossa, Paran, Brazil
Department of Pediatric Dentistry, School of Dentistry, Ponta Grossa State University, Ponta Grossa, Paran, Brazil
3
Department of Orthodontics, School of Dentistry, Ponta Grossa State University, Ponta Grossa, Paran, Brazil
4
Department of Dental Radiology, School of Dentistry, State University of So Paulo, So Jos dos Campos, So Paulo, Brazil
2
Abstract
Purposes: This study employed a posteriori registration and subtraction of radiographic images to quantify the
apical root resorption in maxillary permanent central incisors after orthodontic treatment, and assessed whether the
external apical root resorption (EARR) was related to a range of parameters involved in the treatment.
Materials and Methods: A sample of 79 patients (mean age, 13.52.2 years) with no history of trauma or endo
dontic treatment of the maxillary permanent central incisors was selected. Periapical radiographs taken before and
after orthodontic treatment were digitized and imported to the Regeemy software. Based on an analysis of the posttreatment radiographs, the length of the incisors was measured using Image J software. The mean EARR was
described in pixels and relative root resorption (%). The patients age and gender, tooth extraction, use of elastics,
and treatment duration were evaluated to identify possible correlations with EARR.
Results: The mean EARR observed was 15.4412.1 pixels (5.1% resorption). No differences in the mean EARR
were observed according to patient characteristics (gender, age) or treatment parameters (use of elastics, treatment
duration). The only parameter that influenced the mean EARR of a patient was the need for tooth extraction.
Conclusion: A posteriori registration and subtraction of periapical radiographs was a suitable method to quantify
EARR after orthodontic treatment, and the need for tooth extraction increased the extent of root resorption after
orthodontic treatment. (Imaging Sci Dent 2016; 46: 17-24)
oot Resorption; Orthodontics; Subtraction Technique; Image Processing, Computer-Assisted; Tooth Extraction
Key words: R
Introduction
The interaction between orthodontic forces and the peri
odontal ligament leads to an inflammatory phenomenon
that induces apical resorption by clastic activity1 without
clinical symptoms. This phenomenon is known as external
apical root resorption (EARR), and it is an undesirable2
and irreversible side effect of orthodontic treatment.
The reported occurrence of EARR is between 48% and
Received October 1, 2015; Revised November 4, 2015; Accepted November 22, 2015
*Correspondence to : Prof. Eliane Maria Kreich
Department of Dental Radiology, School of Dentistry, Ponta Grossa State University,
General Carlos Cavalcanti Avenue, #4748, CEP 84030-900, Ponta Grossa, Paran,
Brazil
Tel) 55-42-99171983, Fax) 55-42-32203102, E-mail) elianekreich@gmail.com
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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A posteriori registration and subtraction of periapical radiographs for the evaluation of external apical root resorption after orthodontic treatment
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A B
A B
Fig. 2. External apical root resorption is evaluated by the measurement of the long axis of the maxillary central incisors at baseline (A,
Image 1) and in the registered image (B, Image 3).
C D
E F
Fig. 1. Illustrative images of the post-processing procedures of
periapical radiographs for the right maxillary central incisor. Periapical radiographs at baseline (A, Image 1) and after orthodontic
treatment (B, Image 2) were digitalized. The same reference
points are tagged in the pre-treatment (C) and post-treatment (D)
radiographs to align the images and to generate the posteriori registration of Image 3(E). The quality of the registered image (E) is
confirmed by the fact that the subtracted image (F) exhibited the
least possible structural noise.
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A posteriori registration and subtraction of periapical radiographs for the evaluation of external apical root resorption after orthodontic treatment
Table 1. Mean values of the length of the upper central incisors, angle formed by the maxillary incisor long axis and the nasion line (1.NA),
and linear distance between the most anterior point of the maxillary central incisor and the NA line (1-NA) before and after orthodontic
treatment
Pre-orthodontic treatment
Post-orthodontic treatment
Difference
P-value by paired t-test
Length (pixels)
1.NA ()
1-NA (mm)
302.730.2
287.231.6
15.412.1
(5.1%)
p<0.001
23.67.0
22.26.3
1.48.7
(6.0%)
p = 0.152
5.82.4
5.02.2
0.94.0
(15.0%)
p = 0.0207
Discussion
Statistical analysis
The obtained data showed a normal distribution (Shapiro-Wilk). Therefore, the comparisons between mean
tooth length, 1.NA, and 1-NA before and after orthodontic
treatment were made using the paired t-test. The Students
t-test was used to compare the parameters of gender, age,
tooth extraction, elastics use, and treatment duration. The
statistical analysis was conducted using SigmaPlot 12.0
(Systat Software Inc, San Jose, CA, USA), with the significance level set at p = 5%.
Results
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Table 2. Mean values of external apical root resorption (EARR) and relative root resorption after orthodontic treatment according to different parameters.
Gender
Male (n = 22; 27.9%)
Female (n = 57; 72.2%)
Age (years)
10 to 12 (n = 32; 40.5%)
>12 (n = 47; 59.5%)
Tooth extraction
Yes (n = 37; 46.8%)
No (n = 42; 53.2%)
Usage of elastics
Yes (n = 60; 76.0%)
No (n = 19; 24.1%)
Treatment duration
12 to 24 months (n = 43; 54.4%)
25 months or more (n = 63; 79.8)
17.510.4
14.610.8
5.4%
5.0%
13.98.8
16.511.8
4.7%
5.4%
19.013.3
12.36.5
5.1%
4.3%
15.210.7
16.311.0
5.2%
5.3%
14.710.8
16.410.6
5.0%
5.3%
p = 0.14
p = 0.16
p = 0.003
p = 0.35
p = 0.23
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A posteriori registration and subtraction of periapical radiographs for the evaluation of external apical root resorption after orthodontic treatment
rate of EARR,35 but most studies have reported that gender had no influence at all on EARR.6,9,25,26,38-40
Regarding to the age criterion, it is often stated that
adults experience more root resorption than teenagers undergoing orthodontic treatment.3,39 This may be related to
the creation of more hyalinized areas, longer hyalinization
duration, and slower healing patterns in adults.31,35 Contrastingly, a systematic review has affirmed that chronological age is not a primary indicator of root resorption,3
but the degree of root formation may be.3,9,41
In our study, the patients age varied between 10 and 19
years. Since complete root formation was an inclusion
criterion for our sample, all patients had completed root
formation. Our upper limit confined the sample to teenage patients. Therefore, the absence of a statistically significant age difference in our sample was expected and
agrees with the observations of maxillary incisors made
by other researchers.25,26,39,42 Nonetheless, it is important
to point out that the criteria of gender and age may not
be reliable predictors of root shortening after orthodontic
treatment.
The multifactorial etiology of EARR complicates the
establishment of a definitive relation with the several factors that cause resorption. This is also related to the heterogeneity of the study designs. The methodologies used
to measure EARR are not standardized, and variations are
present in the radiographic images used for analysis. In
this regard, our study made the contribution of proposing
a methodology that reduces subjectivity when evaluating
root resorption and facilitates early diagnosis. Regardless,
further research on this topic is needed, especially controlled clinical trials with longer follow-up periods.
It may be concluded that a posteriori registration and
subtraction of periapical radiographs is a suitable method
for quantifying EARR after orthodontic treatment, and
that the need for tooth extraction increased the extent of
root resorption after orthodontic treatment.
References
1. de Freitas JC, Lyra OC, de Alencar AH, Estrela C. Long-term
evaluation of apical root resorption after orthodontic treatment using periapical radiography and cone beam computed
tomography. Dental Press J Orthod 2013; 18: 104-12.
2. Roscoe MG, Meira JB, Cattaneo PM. Association of orthodontic force system and root resorption: a systematic review.
Am J Orthod Dentofacial Orthop 2015; 147: 610-26.
3. Tieu LD, Saltaji H, Normando D, Flores-Mir C. Radiologically determined orthodontically induced external apical root
resorption in incisors after non-surgical orthodontic treatment
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A posteriori registration and subtraction of periapical radiographs for the evaluation of external apical root resorption after orthodontic treatment
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